Pruitthealth - Sylvester

In the surveyor’s words

From the most serious findings on record at Pruitthealth - Sylvester, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF759Dec 2, 2021

  Based on observation, interview, record review, and policy review, the facility failed to ensure the medication error rate was less than 5%. A total of 38 opportunities were observed with nine errors for three residents (R#5, R#6, and R#7) for an error rate of 23%. Findings include: The facility had a Medication Administration: General Guidelines policy. The policy documented that if the facility receives its medications packed with the AdvantageRx system the authorized personnel will compare the AdvantageRx bag to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At the end of each medication pass, the person administering the medications reviews the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF554Jul 19, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents the facility failed to ensure two of 32 sampled residents (R) (R58) and (R67) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility. A review of the facility policy titled, Self-Administration of Medications by Patients/Residents dated 12/11/2025 documented, Each patient/resident who desires to self-administer medication is permitted to do so if the health care center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients… […]

• No harm, potential for more than minimal, isolatedF656Jul 19, 2026

  Based on observations, staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to follow care plans for two of 32 sampled residents (R) (R81) and (R41). This deficient practice had the potential to place R81 at risk of not receiving treatment and/or care in accordance with their needs.Findings include: Record of the facility policy titled Care Plan dated 10/21/2025 3. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient/resident 's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident 's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive care plan should describe the… […]

• No harm, potential for more than minimal, isolatedF695Jul 19, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that three of 27 residents (R) (R81), (R2), and (R41) receiving oxygen were administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R81, at risk for respiratory complications and a diminished quality of life. Findings include: Record review of the facility policy titled, Oxygen Administration, documented it is the policy of (facility) to provide oxygen safely and accurately to appropriate patients/residents. 4. […]

• No harm, potential for more than minimal, isolatedF761Jul 19, 2026

  Based on observations, staff interviews, and review of facility policy titled, Medication Storage Policy, the facility failed to ensure medications were secured for one of four medication carts reviewed. Findings include:The facility policy titled Medication Storage Policy, dated 11/10/2025, revealed under Policy Statement: . It is the policy of [facility] to ensure all medications are stored, secured, and maintained in accordance with federal, state, and facility standards to promote patient safety and regulatory compliance. […]